Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home, Inc during CMS and state inspections, most recent first.
The facility did not serve meals within the required 30-minute window, resulting in some residents waiting up to 47 minutes for their food. Staff delays were caused by the need to debone chicken and cut up food at the tables, as well as waiting for meal carts to be returned. A resident reported that long waits for meals were common, and staff confirmed that the observed delays did not meet facility standards.
Dietary staff did not consistently wear required beard and moustache coverings while preparing and serving food, contrary to facility policy. Additionally, the ice machine's filtration system was not maintained according to recommended intervals, with filters overdue for replacement and visible mineral buildup and rust present. Staff interviews confirmed lapses in both facial hair covering use and filter maintenance.
Two residents receiving antipsychotic medications, including one with severe cognitive impairment and another with multiple psychiatric diagnoses, were not provided or documented with education regarding the risks, benefits, or alternative treatments for these medications. Facility staff confirmed the absence of such documentation, resulting in a deficiency related to informed consent for antipsychotic use.
Surveyors found that two residents were prescribed psychotropic medications without proper documentation of approved indications in their medical records. One resident received an antidepressant for depression without a corresponding diagnosis, and another was given a hypnotic for insomnia without insomnia being documented. Facility policy requires such medications to be used only for specific, documented conditions, but this was not followed in these cases.
A resident was discharged from the facility without the required notification to the state ombudsman. Facility policy mandates ombudsman notification upon discharge, but staff interviews and record reviews confirmed that only hospital transfers were reported, and no documentation existed for the resident's discharge notification.
A resident with multiple mental health diagnoses was admitted from another nursing home without a current PASARR Level 1 screening, as required by facility policy. The only available PASARR evaluation was over a year old and completed at the previous facility. The Social Services Director confirmed that a new screening was not requested prior to admission.
A resident experienced two unwitnessed falls, but the care plan was not updated with new interventions or goals until several days after the incidents, despite facility policy requiring prompt updates by the DNS and MDSC.
The facility did not adhere to food safety requirements, including the removal of dented cans, proper hairnet placement, and hand hygiene practices. Observations showed dented cans of apple pie filling in storage, a disconnected syrup fastener connector on the floor, and dietary aides touching the top portion of plates while serving meals. Hand hygiene was not consistently performed for the required 20 seconds, and a dietary aide was seen with a hairnet improperly placed. The Dietary Manager confirmed the lack of a policy for dented cans, improper syrup connector placement, and non-compliance with hand hygiene and plate handling protocols.
A facility failed to treat a resident with dignity by discussing their personal bowel habits in a public dining area. The resident confirmed a preference for privacy, and the DON acknowledged the inappropriateness of the public conversation and the lack of a relevant policy.
The facility staff failed to evaluate a resident's ability to self-medicate, leading to medications being left unattended on a dining room table. The resident did not have a Self-Administration of Medication assessment or a physician's order for self-administration, contrary to facility policies.
The facility failed to properly clean a resident's CPAP equipment, as observed multiple times with white specks inside the mask. Interviews revealed inconsistencies in the cleaning schedule, and the Director of Nursing confirmed the need for cleaning. The resident, who is severely cognitively impaired, was not provided with the required care according to the manufacturer's instructions.
The facility failed to keep a medication cart locked when out of the eyesight of a nurse and did not label and date an eye drop medication for a resident. Both the LPN and the DON confirmed these deficiencies, which were against the facility's policies on administering and labeling medications.
The facility failed to perform proper hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart. An LPN washed hands for only 5 seconds instead of the required 20 seconds and did not perform hand hygiene between residents. Additionally, the LPN picked up a dropped pill with bare fingers and placed it back in the medication cup for another resident. These actions were confirmed by the LPN and the DON, who acknowledged that the facility's hand hygiene policy was not followed correctly.
Delayed Meal Service Due to Insufficient Dietary Staffing and Inefficient Processes
Penalty
Summary
The facility failed to ensure that meals were served within the allotted time frames established by staff, potentially affecting all residents served from the kitchen. Observations during the noon meal revealed that some residents waited up to 47 minutes after the scheduled mealtime to receive their food. Residents were observed seated and waiting, with some consuming desserts and drinks before the main meal was served. Dietary staff were delayed in serving meals due to the need to debone chicken wings and cut up food at the tables, which extended the overall meal service time. The process of serving was further slowed as dietary staff had to wait for meal carts to be returned before continuing to serve additional tables. Interviews with residents and staff confirmed that extended wait times for meals were not uncommon, with one resident stating it was typical to wait up to an hour for lunch and supper. The Dietary Manager acknowledged that all meals are supposed to be served within 30 minutes of service start, and that the delays observed were not acceptable. The facility's posted mealtimes and staff training both indicated a 30-minute window for meal service, but this standard was not met during the observed meal, as confirmed by both dietary staff and the facility administrator.
Failure to Ensure Dietary Staff Facial Hair Coverings and Proper Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure that all dietary staff with beards and moustaches wore appropriate facial hair coverings while working in the kitchen, as required by facility policy. Multiple observations over two days showed that cooks were serving meals without beard and moustache coverings, despite the policy stating that staff must be clean shaven or wear a beard guard or mask covering the entire area. Interviews with the involved staff confirmed that the coverings were not worn at all times, with one staff member indicating they were a new hire and still learning the procedures. Additionally, the facility did not maintain a safe and effective cleaning routine for the ice machine filtration system. Observations revealed that one filter was visibly dirty and past its change date, while other filters had dates indicating they had not been changed according to the required intervals. The area where cups and pitchers are filled with ice showed mineral deposits and rust. Interviews with maintenance staff confirmed that the filters had not been changed as required and that there was no written policy or manual for the filtration system. The facility administrator acknowledged the presence of mineral buildup and rust on the ice machine.
Failure to Inform Residents or Representatives of Antipsychotic Medication Risks and Alternatives
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about the risks, benefits, and alternative treatments associated with the use of antipsychotic medications for two residents. For one resident with severe cognitive impairment and a diagnosis of dementia, Seroquel was administered daily from admission, and documentation showed the resident experienced excessive sleepiness, prompting a physician to note probable overmedication. Despite ongoing administration and monitoring for side effects, there was no documentation in either the electronic or paper medical records that the resident or their family had been educated about the antipsychotic medication. Another resident with diagnoses including unspecified dementia with behavioral disturbance, bipolar disorder, anxiety disorder, and a history of alcohol abuse was also prescribed multiple psychotropic medications, including Seroquel. The care plan and medication records confirmed regular administration of these medications and ongoing behavioral monitoring. However, there was no documentation that the resident or their family had been informed of the risks, benefits, or alternative treatments for the antipsychotic medication. Interviews with facility staff, including the Director of Nursing Services and the Minimum Data Set Coordinator, confirmed the absence of documentation regarding resident or family education on antipsychotic medication use for both residents. The lack of documented education and informed consent for antipsychotic medication use constituted the deficiency identified during the survey.
Failure to Ensure Approved Indications for Psychotropic Medication Use
Penalty
Summary
Surveyors identified that the facility failed to ensure psychotropic medications were prescribed with approved indications for use for two of five sampled residents. Facility policy requires that antipsychotic medications be used only for specific, documented conditions and after non-pharmacological interventions have been attempted, except in emergencies. The policy also mandates that medications such as antipsychotics and antidepressants be prescribed only when necessary to treat specific conditions, and that diagnoses alone do not warrant their use without supporting behavioral symptoms and documentation. For one resident with diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease, anxiety disorder, and insomnia, the medical record showed the use of mirtazapine for depression and insomnia, and Seroquel for dementia-related symptoms. However, there was no diagnosis of depression documented in the resident's medical record or on the active diagnosis sheet, despite the ongoing administration of mirtazapine for that indication. Behavioral monitoring documented symptoms such as sadness, tearfulness, wandering, and anxiety, with interventions attempted but with mixed or unchanged results. Another resident with unspecified dementia, bipolar disorder, and anxiety disorder was prescribed Ambien for insomnia, Klonopin for anxiety, Remeron for bipolar disorder, and Seroquel for bipolar disorder. The care plan referenced the use of psychotropic medications for bipolar disorder and insomnia, but there was no diagnosis of insomnia documented in the medical record or on the active diagnosis sheet, despite the administration of Ambien for that purpose. Behavioral monitoring noted episodes of frustration and verbal aggression, with interventions resulting in either improvement or no change.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge, as required by both facility policy and regulatory standards. According to the facility's Discharge Planning Process policy, notification to the ombudsman should occur by fax on the date of discharge. Record review showed that a resident was admitted and later discharged, but there was no documentation of ombudsman notification for this discharge. The facility's Record of Transfers/Discharges also did not contain evidence of such notification for the resident in question. Interviews with facility staff revealed confusion regarding responsibility for ombudsman notifications. The Social Services Director was initially unsure who was responsible, later indicating that the DON handled notifications. The DON confirmed that the facility only notifies the ombudsman for hospital transfers, not for discharges, and acknowledged that no notification was made for this resident's discharge. This lack of notification was confirmed through both documentation review and staff interviews.
Failure to Complete PASARR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level 1 screening was completed prior to the admission of a resident with mental health diagnoses. According to facility policy, all applicants must be screened for serious mental disorders or intellectual disabilities before admission, and a record of this screening must be maintained in the resident's medical record. The policy also specifies that the Social Services Director is responsible for tracking each resident's PASARR status. Exceptions to this requirement are limited to individuals readmitted directly from a hospital or those certified by a physician as likely to require less than 30 days of nursing facility services. A review of the medical record for a resident admitted from another nursing home revealed that the only available PASARR Level 1 evaluation was completed over 14 months prior to admission to the current facility. There was no evidence of a current PASARR Level 1 screen within 30 days before or after the resident's admission, despite the resident having diagnoses of Post Traumatic Stress Disorder, Anxiety, Depression, and Unspecified Psychosis. The Social Services Director confirmed that a current PASARR Level 1 screen was not requested prior to the resident's admission, and the existing evaluation was from the previous facility.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with new interventions after each fall for one resident. Record review showed that the resident experienced two unwitnessed falls within a five-day period. Despite the facility's policy requiring the care plan to be updated by an interdisciplinary team after such incidents, the last update related to falls was completed over a month prior to the most recent falls, and no new interventions or goals were added following these events. Interviews with nursing staff and administrative personnel revealed that only the Director of Nursing Services (DNS) and the Minimum Data Set Coordinator (MDSC) were responsible for updating care plans. Both confirmed that the care plan for the resident in question was not updated on the same day or the day after the falls, as required by facility policy. The MDSC acknowledged that the care plan had not been revised until several days after the incidents, contrary to established procedures.
Food Safety Protocols Not Followed in Dietary Department
Penalty
Summary
The facility failed to ensure food safety requirements by not removing dented cans for resident consumption, maintaining correct placement of hairnets while prepping and plating food, performing hand hygiene for 20 seconds prior to plating residents' food, preventing contamination by improperly holding dining plates while serving meals, and improperly storing the fountain dispenser line. Observations revealed dented cans of apple pie filling were stored for use in the dry storage area, the syrup fastener connector was disconnected and lying on the floor, dietary aides touched the top portion of plates while serving meals, and hand hygiene was not consistently performed for the required duration. Additionally, a dietary aide was observed with a hairnet improperly placed, allowing hair to be outside the net while handling food for residents. The Dietary Manager acknowledged the lack of a policy for dented or damaged cans, confirmed the presence of the dented cans in storage, and acknowledged the need for proper removal. The manager also confirmed the improper placement of the syrup connector, lack of adherence to hand hygiene protocols, and improper handling of meal plates by dietary aides. Education had been provided to staff previously on these matters, indicating awareness of the correct procedures. Interviews with staff members confirmed the need for adherence to hand hygiene protocols, proper hairnet usage, and correct handling of meal plates to prevent contamination and ensure food safety for the residents.
Violation of Resident Dignity in Public Setting
Penalty
Summary
The facility failed to treat Resident 24 with dignity by discussing their personal bowel habits in a public setting. During an observation in the dining area, a Registered Nurse (RN-A) approached Resident 24 at their assigned seat and held a conversation about their bowel habits loud enough for table mates and others in the room to hear. Resident 24 later confirmed in an interview that they preferred such personal matters to be kept private. The Director of Nursing (DON) acknowledged that private conversations regarding bowel habits should not occur in public spaces and revealed that the facility lacked a policy for handling personal conversations in public areas.
Failure to Evaluate Resident's Ability to Self-Medicate
Penalty
Summary
The facility staff failed to evaluate Resident 42's ability to self-medicate, as required by the facility's policies. Resident 42, who has diagnoses including congestive heart failure, hypertension, atrial fibrillation, vitamin deficiency, and pain, was observed during a morning medication pass. LPN-A placed multiple medications in a cup and left them on the dining room table for Resident 42 without observing the resident taking the medications. The medications remained on the table for an extended period, and LPN-A confirmed that this practice was common with alert and oriented residents due to time constraints, despite acknowledging it was inappropriate. Further investigation revealed that Resident 42 did not have a Self-Administration of Medication assessment completed, nor was there a physician's order for self-administration in the resident's Medication Administration Record. The facility's policies clearly state that residents may only self-administer medications if deemed safe by the attending physician and the Interdisciplinary Care Planning Team. The Director of Nursing confirmed that medications should not be left with residents and should be observed as taken, highlighting a clear breach of protocol in this instance.
Failure to Clean CPAP Equipment
Penalty
Summary
The facility failed to provide proper cleaning for a resident's CPAP equipment. Resident 55, who has a diagnosis of obstructive sleep apnea and is severely cognitively impaired with a BIMS score of 4, was observed multiple times with a CPAP mask that had white specks on the inside. The CPAP mask was found assembled and laying in the bedside drawer on several occasions, indicating it had not been cleaned as required. Interviews with medical assistants revealed inconsistencies in the cleaning schedule, with one assistant stating the mask is cleaned in the mornings and another admitting it had not been cleaned by the designated time. The Director of Nursing confirmed that the CPAP masks need to be cleaned. The manufacturer's cleaning instructions specify daily wipe-downs, gentle washing with mild detergent, thorough rinsing, and air drying. Despite these guidelines, the observations and interviews indicate that the facility did not adhere to the prescribed cleaning regimen for Resident 55's CPAP equipment, leading to the deficiency noted in the report.
Medication Cart and Labeling Deficiencies
Penalty
Summary
The facility failed to keep a medication cart locked when it was out of the eyesight of a nurse. An observation revealed an unlocked medication cart on hall 400 while the nurse responsible for it was inside a resident's room further down the hall. Both the LPN and the DON confirmed that the medication cart should not have been left unlocked when it was not within the nurse's eyesight. The facility's policy on administering medications, revised in April 2007, states that the medication cart must be kept closed and locked when out of sight of the medication nurse or aide, and it must be clearly visible to the personnel administering medications. Additionally, the facility failed to label and date an eye drop medication for a resident. During a medication pass, it was observed that a box of Regener-Eyes eye drops did not have a label indicating who the medication was for or directions on how to administer it. The box and bottle were also not dated to indicate when the eye drop bottle was opened. The LPN and the DON confirmed that the medication should have been labeled and dated. The facility's policy on labeling medication containers, revised in April 2007, requires that all medications maintained in the facility be properly labeled, including over-the-counter drugs, which should have the resident's name, expiration date, and directions for use.
Failure to Perform Proper Hand Hygiene and Medication Handling
Penalty
Summary
The facility failed to perform proper hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart. An observation revealed that an LPN prepared medications for a resident and administered them through a J-tube, followed by nasal spray and eye drops, without performing adequate hand hygiene. The LPN washed hands for only 5 seconds instead of the required 20 seconds and did not perform hand hygiene between residents. Additionally, the LPN picked up a dropped pill with bare fingers and placed it back in the medication cup for another resident. These actions were confirmed by the LPN and the Director of Nursing, who acknowledged that the facility's hand hygiene policy was not followed correctly. The facility's hand hygiene policy requires staff to wash hands for at least 20 seconds with soap and water, covering all surfaces of hands and fingers, including areas under and around fingernails. The policy also states that gloves do not replace hand washing and that hands should be washed after removing gloves. The facility's medication administration policy mandates following established infection control procedures, including handwashing and the use of gloves. The failure to adhere to these policies was observed during the medication administration for three residents, highlighting a significant lapse in infection prevention and control practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Minden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Carmel Home - Keens Memorial | 15.2 mi | ★★★★★ | 9 | 0 |
| Mother Hull Home | 15.4 mi | ★★★★★ | 14 | 0 |
| Good Samaritan Society - St Luke's Village | 15.4 mi | ★★★★★ | 14 | 0 |
| Brookestone Gardens | 15.6 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society - St John's | 16.1 mi | ★★★★★ | 18 | 0 |
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